Landi and colleagues examined emotional dysregulation as a multidimensional clinical feature in adults with ADHD rather than reducing it to impulsivity or visible emotional behavior.
Useful distinction: this study supports emotional dysregulation as a clinically meaningful dimension in adults with ADHD. It does not establish that emotional dysregulation is a separate ADHD diagnosis, prove that ADHD causes every emotional difficulty, or show that the correlated features identified in the study cause one another.
What the researchers asked
The researchers wanted to examine how emotion-regulation difficulties appeared within a clinically diagnosed adult ADHD sample and how those difficulties related to ADHD presentation, psychiatric comorbidity, substance use, anxiety, depression, impulsivity, camouflaging, problematic internet use, functioning, and quality of life.
Study design
- Design: cross-sectional observational clinical study
- Sample: 231 adults with ADHD from a specialized clinic in Italy
- ADHD diagnosis: DSM-5 ADHD confirmed with DIVA-5
- Emotion-regulation measure: Difficulties in Emotion Regulation Scale (DERS)
- Other measures: current and retrospective ADHD symptoms, anxiety and depression measures, Barratt Impulsiveness Scale, Internet Addiction Test, Camouflaging Autistic Traits Questionnaire, substance-use status, and ADHD-related quality of life
Because the study was cross-sectional, it can identify relationships among variables but cannot establish which variable caused another.
What the DERS measures
The DERS separates emotion-regulation difficulty into six domains:
- Nonacceptance: difficulty accepting emotional responses
- Goals: difficulty staying goal-directed while distressed
- Impulse: difficulty controlling behavior while distressed
- Awareness: reduced attention to or awareness of emotional states
- Strategies: limited perceived access to useful regulation strategies
- Clarity: difficulty identifying and understanding what one is feeling
That multidimensional approach is useful because emotional dysregulation is not synonymous with emotional impulsivity.
Main findings
Emotional dysregulation was substantial in this clinical ADHD sample
The mean DERS total score was elevated relative to Italian reference values. The largest relative elevation was in emotional clarity, followed by difficulty pursuing goals when distressed, nonacceptance, and impulse control. Strategy difficulty was more modest, and awareness was only slightly elevated.
The pattern matters clinically. Someone can notice that they are distressed without being able to identify the emotion clearly, understand what triggered it, or access the response they want in the moment.
Combined presentation showed greater emotion-regulation difficulty
Participants with combined-presentation ADHD had higher DERS scores than those with predominantly inattentive presentation. The predominantly hyperactive/impulsive subgroup was extremely small, so the study should not be used to make broad claims about all three ADHD presentations.
Current substance-use disorder was associated with higher dysregulation
Participants with a current substance-use disorder had higher emotional-dysregulation scores. In multivariable analyses, current substance-use disorder remained independently associated with DERS scores.
The design does not tell us whether substances were being used to regulate emotion, whether emotion-regulation difficulty increased substance-use risk, whether both were influenced by another factor, or some combination.
Anxiety was strongly related
Trait anxiety was independently associated with greater emotional dysregulation in the adjusted models.
This supports assessing anxiety alongside emotion regulation. It does not establish that anxiety is an ADHD regulation strategy or that anxiety is necessary for ADHD adults to function.
Emotional dysregulation was not explained by impulsivity alone
DERS scores correlated with impulsivity, but impulsivity did not remain an independent predictor in the final multivariable model. That supports treating emotional dysregulation as broader than simply "acting before thinking."
Camouflaging and problematic internet use were correlated—but not independent predictors
Greater DERS scores were associated in bivariate analyses with greater camouflaging and problematic internet use. Neither remained an independent predictor in the final multivariable model.
This is an important evidence limit. The study supports an association, not the claim that masking causes dysregulation, dysregulation causes masking, internet use is a regulation strategy, or any of these patterns feed each other in a specific causal direction.
Quality of life was related
Greater emotional dysregulation was associated with poorer ADHD-related quality of life, and quality of life remained independently associated with DERS scores in adjusted analyses.
That makes emotion regulation clinically relevant even though it is not one of the core DSM-5 ADHD criteria.
What the study did not establish
The study did not show:
- that emotional dysregulation is unique to ADHD
- that emotional dysregulation should become a diagnostic criterion by itself
- that the DERS pattern found here applies to every ADHD adult
- that women have the same pattern as men or that this study explains female-specific emotional difficulties
- that masking, anxiety, substance use, or internet use causes emotional dysregulation
- that emotional dysregulation causes those associated behaviors
- that any particular therapy or regulation strategy is effective
- that "nervous system dysregulation" is the mechanism behind the findings
There was no healthy or clinical comparison group, so the study cannot tell us how specific these patterns are to ADHD.
Why the emotional-clarity finding is useful
The clarity finding gives clinicians and ADHD adults a more precise question than "Can you control your emotions?"
Useful questions include:
- Do you know what you are feeling while it is happening?
- Do you know what changed just before the emotion intensified?
- Can you tell the difference between anger, shame, fear, hurt, overload, exhaustion, and urgency?
- What happens to attention, working memory, and decision-making when you are upset?
- Can you access a strategy you already know when the emotion is strong?
- Do you understand the feeling more clearly only after the situation is over?
Emotion words are only one route. Body sensations, urges, thoughts, context, and behavior can also provide information when an exact label is not available.
Clinical translation
A broader ADHD formulation can examine:
emotion + attention + executive functioning + sensory load + body signals + sleep + stress + relationships + environment + co-occurring conditions.
That is more useful than treating every difficult reaction as an impulse-control problem.
When a person uses scrolling, isolation, food, substances, work, shopping, or another behavior during distress, the function can be explored without assuming the study has already explained it. Ask what the behavior changes in the short term, what demand or feeling is present, what it costs, and what other supports could serve the same need more safely or sustainably.
Relevance to ADHD women
This was a mixed-sex clinical study and was not designed as a women-specific analysis. It can strengthen the general evidence that emotion regulation deserves direct attention in adult ADHD, but women-specific factors such as menstrual-cycle changes, PMDD, pregnancy/postpartum changes, perimenopause, gendered expectations, masking, stigma, and delayed diagnosis require separate evidence.
Source
Landi P, Olivola M, De Ciechi A, et al. Emotional Dysregulation as a Clinically Relevant Dimension of Adult ADHD: A Multidimensional Clinical Study. Brain Sciences. 2026;16(6):577. DOI · PubMed